HL Deb 18 July 1966 vol 276 cc346-57

5.27 p.m.

LORD AMULREE rose to ask Her Majesty's Government whether the shortage of medical social workers in the hospital service has not been increased by the disparity between the rates of pay offered by the Ministry of Health and by local authorities, and also by the recently announced revised gradings. The noble Lord said: In rising to put to Her Majesty's Government this Question which, I am afraid, is of a very technical character I should just like to say a word or two on the facts which have led to my putting it down. I would remind your Lordships that the people I am dealing with, the medical social workers, go back quite a long time. The first almoner was appointed by the Royal Free Hospital in 1895. By the time the National Health Service came in, they were common in most of the voluntary hospitals. Their prime duties at that time could be divided into two. The first was to take care of patients' interests, to look after them when they were in hospital, apart from their medical complaints, to look after their families, their pensions and the money which was coming to them and, at the same time—and this is equally important—to assist them to find what sum they could contribute to the cost of their stay in hospital.

The National Health Service came in in 1948, and that took away the second function which I have mentioned. At the same time, a great deal of work that they were doing which was routine went across to clerks (first the almoner's clerks and then the administrative clerks), so that really meant that their work had completely changed. They were now doing what was called case work, and they took a great deal of care and a great deal of interest in the patients under the care of the doctors in the hospital. The next move—and I have only two more briefly to refer to—was when the Institute of Almoners at the time joined up with eight other bodies to form the Standing Conference of Organisations of Social Service. Then, in September, 1965, the almoners changed their name to medical social workers. In 1959, the Young husband Committee, reporting on the need for social workers in England and Wales, said that to make a complete coverage of all the hospitals—that is, the old voluntary hospitals, together with a large number of local authority hospitals which had been greatly improved since the National Health Service came into operation in 1948—would require between 2,500 and 3,000 workers. I do not think that that number has ever been reached, and that is the situation at the present time.

My Lords, the difficulty to which I now refer arose in part from the negotiations with the Whitley Council for new salaries and gradings. Those negotiations gave the medical social workers a 3 per cent. increase in January, 1965, which is set forth in one of the circulars issued by the Ministry. One sees in the covering circular that it was the intention that more medical social workers should be employed by the local authorities than at the present time, that the hospitals should have complete access to medical social workers employed by local authorities, and, at the same time that those from the local authorities should be able to go into the hospitals.

But something went wrong with that rather pleasant thought, because the local authorities were given a far more flexible, as one might call it, interpretation of the salary scale than were the hospitals. In the National Health Service scales laid down by the Treasury the control is a great deal more rigid than in the local authority service. What occurred was that, because the total number of medical social workers was not as great as was required for a complete coverage, and because the local authorities could pay more than the hospitals, and did so, the medical social workers, being human beings, felt that they should go where there was more money. At the same time, we found there were certain rather curious differences made in the gradings upon which their salaries depended.

In the first place, there appears to be no particular standard laid down for gradings, so that some hospital management committees adopted one standard and others adopted a quite different standard. The salary grading of head medical social workers depended on the number of staff working under them. That is not a very fair way of deciding a grading and salary, because it can lead to two injustices, if I may use that word. First, my Lords, supposing there are more people available than are required, it will tend to overstaffing, so that by employing more people a head worker can be paid a little more himself. I do not think that this applies to medical social workers, because their numbers are not sufficient to encourage hospitals to overstaff. But it does mean—and it is rather sad—that a large number of senior social workers who, because of a shortage of staff in the past, and a shortage of money to pay the staff that was available, had to work under great difficulty, with staffs far smaller than their establishments are now, as it were, demoted in their grade simply because the numbers they employ are not large enough to justify their retention in the grade in which they were before.

There is another purely technical point which I do not understand. There are medical workers known as senior medical social workers who, apparently, are not counted in the establishment of the head social worker. So if a head social worker has a certain number of senior social workers under him they do not count as part of his establishment. I think it a rather sad thing. The effect of this has been to cause, together with a certain amount of internal trouble in the service (a matter that I do not propose to go into now), an unsatisfactory state among these people. It means that there has been discontent among the medical social workers who have felt insecure and puzzled about their future.

In the same way, there has been some sign that there may be more people leaving the service than the service can stand. I have made a number of inquiries, limited to that part of the world around London, where heads of departments have gone and have not been replaced. I do not wish to quote all the examples which I have: I am sure that the noble Lord who is to reply knows to what I refer, and I can give him the examples later, if he wishes. There have been cases where head social workers have gone, and other workers have gone, and they have been replaced by part-time workers; and there are cases where a complete department appears to have faded away. I myself had a very good social worker and she is proposing to leave in September to go to a teaching job, which is much better paid. She will be replaced by someone from another department, which means that, although my department will have a social worker, some other department will be denuded, because there are not enough of these people applying for jobs in hospitals.

I thing I am right in saying that in July of this year there is to be some agreement about salaries in local authorities and I wish to know (this is one of the questions which I wish to put to the noble Lord): will it be possible to tie the salaries of medical social workers in the hospitals to those of the local authorities, so that there may be complete parity and no question of a rush from one side to the other? I was going to read to your Lordships a long quotation from the recent report of the Institute of Medical and Social Workers, but I do not think that I shall. It merely emphasises what I have already said. If there are not enough people to go round, the authority which can pay most will get the services of those people who are available. I know that that is rather a sad thing to say; but medical social workers, like doctors, lawyers, clergymen and everyone else, are human beings, and if we can make a little more money by doing the same kind of work for someone else, we tend to do so.

My Lords, before I sit down I should like to say (although I am sure that it does not need me to say it) what an enormous value the work of medical social workers has to the work of doctors in hospital. If we were robbed of our social workers, I do not think that we could do half the amount of work which we do at the present time. That applies particularly to the work which I have been doing: taking care of the elderly, the chronic sick and the long-term sick, who pose enormous problems for their families when they are discharged. The work could not be done without the help of really first-class medical social workers.

It may be said—and there is a certain amount to be said for it—that this work could be done by social workers employed by the local authority. So it can be, up to a point. It is not a very satisfactory way of doing it, and it can be done, I think, only when you have one hospital department dealing with one local authority. Then you have one social worker, and they can come together and work as a team. But in a large number of departments they deal with more than one local authority. There is one that I have in mind at the present time where the doctor in charge deals with the affairs of seven local authorities from which patients come. It is difficult to deal with seven local authorities, and seven social workers coming in, who also have things to do outside and deal with other departments. It makes the work far more efficient and easier if you have one social worker working in one medical department, whether he comes from the local authority (which I do not like very much) or from the hospital service.

So the second question I should like to ask the noble Lord is this: Is it intended to encourage the employment and training of medical social workers in the hospital service? I think it is fairly generally accepted opinion that their training is much better if they start in the hospital field and move into the local authority field. That is the opinion of the Institute of Medical Social Workers, who should know what they are talking about. It is certainly my opinion, and although I may in some respects be prejudiced, in this particular case I do not think I am. Can the Minister say whether it is policy to discourage the training work in hospitals? If it is not policy, can he give any indication of what can be done to even out this disparity between the salaries of the two authorities? If the Minister can give some satisfactory reply to this, it will do a great deal of good to a fine professional body which at the present time is feeling worried and agitated.

5.42 p.m.

LORD ARCHIBALD

My Lords, I hope that I may intervene for a minute or two. I am sure that when the Minister comes to reply he will promise, as usual, that the arguments which have been advanced by the noble Lord, Lord Amulree, and the facts he has offered to provide will be carefully looked into. I would ask him (and I hope I am not out of order in doing so) if he would look into it as though the noble Lord's Question had referred to the shortage of medical social workers and psychiatric social workers. I am sure the noble Lord, Lord Amulree, would agree that the case he has made with respect to medical social workers is almost exactly paralleled by the position of the psychiatric social worker.

LORD AMULREE

My Lords, I entirely agree with what the noble Lord has said. I ought to explain that when I referred to medical social workers I meant to include psychiatric social workers.

LORD ARCHIBALD

I am obliged to the noble Lord. In that case, I need not detain the House for more than a minute more. I should like to give an illustration which came to my notice quite recently. In one of the training hospitals the senior psychiatric social worker—in fact, the supervisor of all the training—had the experience of one of her students, on finishing her training, leaving the hospital to go to a local authority post at a higher salary than that being received by the very senior experienced psychiatric social worker who had been responsible for her training.

That is one aspect of the matter, and there is one more that I should like to quote. If the salary scale in the hospital had been such as to attract that newly-qualified social worker to stay there for a few years and get more experience, instead of leaving, it would have been of benefit to the community. The training in the local authority field is limited, and must of necessity be so. It is training by doing, in a sense, whereas in the hospital it is training by association with and under the guidance of the psychiatrists, the clinical psychologists and so on. If when these workers have completed their training they could be tempted by the salary scale to continue in hospital work for a few years, they would then go out to the local authorities more experienced and, in my opinion, more valuable workers.

I am not suggesting for a moment that they should all be tempted to stay in the hospital field. We all want to see the community care side developed. That means, of course, more workers, however they be allocated between the hospitals and the local authorities. I am not, therefore, decrying the local authority field, but I am suggesting that as the numbers increase, if they do, the hospital salary scale should be such as to attract them to stay in the hospital service until they have acquired that extra training and experience which will make them more valuable in the local authority community field.

5.46 p.m.

THE MINISTER WITHOUT PORTFOLIO (LORD CHAMPION)

My Lords, I am grateful to those noble Lords who have raised this matter, because this is a question that we think ought to be aired: and, strangely though my noble friend Lord Archibald might think it, I propose to say that what has been said will be carefully studied in the Department. The noble Lord, Lord Amulree, said that this was a technical question, and he then steered us through the history and the technicalities in such a way that I now understand it. I agree with the tribute that he paid to those social workers, both in the local authority field and in the hospital field, for the excellent work they do. The difficulty we are facing in this whole question is the fact that both the hospitals and the local authorities need more social workers. This is the position at the moment.

The number of hospital medical social workers in hospitals in England and Wales in terms equivalent to whole-time staff had reached 846 in 1963, but fell to 824 in 1965. In the local authority service, the number of medical social workers and social workers with comparable training was 215 in 1963 and 347 in 1965. These figures, I think, well illustrate the point the noble Lord was making. There has been in these two fields I have mentioned an overall increase of 110 social workers in the period 1963 to 1965, but in this period the hospitals have lost 22 and the local authorities have gained 132. So this is, as I said, a perfect illustration from the figures of the point the noble Lord was putting to me.

The Health Ministers are responsible for both the hospital and local authority health and welfare services. Salaries and grading in the hospital service are a matter, in the first instance, for the Professional and Technical Whitley Council "A", and in the local authority service for the local authorities' National Joint Council for Administrative, Professional and Technical Staffs. Here perhaps some of the difficulty to which the noble Lord referred arises. The position was that the salaries of hospital social workers had generally been lower than in the local authority service until the Whitley Council, in February of this year, negotiated a pay increase which brought hospital salaries and grading into line with those in the local authority agreements. The recent settlement was reached by agreement of the two sides of the Whitley Council, which on the management side included representatives of hospital authorities, including the boards of governors of teaching hospitals, and on the staff side the Institute of Medical Social Workers and the Association of Psychiatric Social Workers, as well as the National and Local Government Officers Association. The negotiators on both sides were well informed of the organisation of hospital social work departments. The next staffing return for each service will relate to September 30, 1966, but whatever these returns show it will be hard to judge the effect of relative pay levels, because movement of staff may also be affected by factors such as personal preference, availability of suitable appointments and other working conditions.

Medical social workers have a very important part to play in hospitals, and their number needs to be increased, but the hospital services should be developed in co-operation with the local authority social work services because the needs of the patient are not confined to his stay in hospital. I am bound to say that I admit here the difficulties to which the noble Lord, Lord Amulree, has pointed. In some cases it is comparatively easy for the hospital to keep in touch with the local authority social worker, but I can see, with him, that the difficulty increases if you get up to, say, seven local authorities to be dealt with by the hospital itself. So certainly this is something which will have to be studied and, if possible, something must be done about it.

Both noble Lords have made it quite clear that the question that is often heard in this matter is: how can we secure an increased number of social workers? This is really the heart of the matter. The training and supply of medical social workers has to be considered together with the training and supply of social workers generally, and this requires the co-operation of the universities, the colleges of further education and other agencies for the provision of courses to meet the needs of the various services in a balanced way. The Minister without Portfolio—and I refer to my right honourable friend and to myself—has under review this matter of co-ordinating the training, recruitment and allocation of social workers and the needs of all the public services, including those of the hospital and local health and welfare services. In the meantime, within the hospital service the Minister of Health has urged hospitals to provide more facilities for practical training for students from university and other courses, and, with the same purpose in view, the recent Whitley agreement has made supervisors of training eligible for the higher salary scales.

The aim of the Whitley Council was to bring hospital salaries and grading into line with those in the local authority agreements in order to achieve balanced recruitment and to facilitate co-operation between the hospital and community welfare services by means of joint and shared appointments. The settlement covered not only qualified medical social workers but also qualified psychiatric social workers and staff without professional qualifications. I think my noble friend can be reasonably satisfied with this assurance about the psychiatric social workers. The task of the negotiators was to translate fifteen different hospital grades into four grades corresponding with the local authority grades which had been based on the recommendations of the Young-husband Report to which the noble Lord, Lord Amulree, referred.

In reducing the number of separate salary scales the settlement was unavoidably unequal in its application to individuals and gave rise to complex problems of assimilation on which it was necessary for the two sides in the normal process of collective bargaining to reach a broad agreement, taking account of all relevant factors, including the fact that the regrading itself produced very large increases for some staff but small immediate increases for others. Under the agreement reached by the two sides no social worker suffered any reduction in salary, many received substantial increases, and the majority will proceed to higher maxima and will have better prospects of movement to higher grades in respect of supervision of staff, teaching or work of special responsibility.

My following paragraph to some extent, I think, answers the point which was made very strongly by the noble Lord, Lord Amulree. The agreement provides for supervisory staff to be graded as senior or head social worker according to the number of basic grade staff in the department. This is simply a method of reflecting the size of the department. It assumes that in large departments there will also be a proportion of higher grade staff; but by excluding these from the count it enables those hospitals trying for the first time to establish a social work department to offer a senior post to a fully qualified social worker, even though there might initially be no more than two unqualified staff in post. The agreement thus gives a wide measure of flexibility according to the circumstances of each hospital group and the form of organisation preferred, whether by a single combined department or a number of separate departments.

The fact that the count is related to the number of basic grade staff, and not total staff, does not mean that higher grade staff need be excluded by the hospital authority from the administrative control of a staff supervisor made responsible for the whole of their social work services. The Whitley Council took note of the possibility that some hospital groups might require an exceptionally large proportion of higher grade to basic grade social workers, and accordingly provided for such cases to be considered individually by the joint secretaries of the Council as regards the effect upon the grading and salary of the head social worker. The extra week's leave allowed for social workers with teaching duties follows the precedent of earlier agreements and accords with the conditions of service of other teaching grades in the hospital service.

While the Whitley agreement is applicable throughout the hospital service, the agreement of the local authorities' National Joint Council is not binding on local authorities in quite the same way. Local authorities have discretion in the starting pay and conditions of individual social workers. If not used with care this discretion could lead to inconsistencies between different authorities and between local authorities and hospitals. This seems to me to be the gravamen of the charge or the complaint which the noble Lord, Lord Amulree, has made. I hope that what I am now going to say will, to some extent, at least, satisfy both noble Lords who have spoken. The local authorities' National Joint Council agreement has been under review as regards the salaries, grading and qualifications of social workers, and the details of a new agreement were announced last week. The management side of the Whitley Council has given no undertaking to follow changes in the local authorities' agreement automatically in all circumstances, but it has agreed that it would consider a review of the hospital settlement if the National Joint Council reviewed the local authorities' agreement.

The Whitley Council will no doubt take note of what has been said in this discussion. That was why to some extent, although I had to reply to it, I welcomed the noble Lord's Question. It is good that councils and various bodies should have not only the assistance of those who appear before them to argue their case and negotiate an agreement, but also the experience of noble Lords who are themselves engaged in this work. I can give the undertaking that what has been said will certainly be studied in the Ministry, and I should expect that the bodies helping to do this work will also consider what has been said in this House to-day.

LORD AMULREE

My Lords, before the noble Lord sits down, I should like to thank him very much indeed for the extremely full statement he has made. I shall study it carefully.